Normally, our blogs address either high-level views of revenue cycle management with an emphasis on billing automation. Or we get into the nitty-gritty of how-to’s for those who either prepare and submit the claims or supervise those who do. What we have discovered, though, among our contacts and clients from the C-Suite to the billing office is that many have asked us, “What is the cloud?” Haven’t you used a word almost all your life, but have never really looked up its definition? Then one day, you find yourself using the word in a conversation only to question your understanding and use of the word. Well, one of those words, we’ve discovered, is the “cloud”. So let’s give you a very quick and stratospheric overview. Here goes.

What is the cloud?

Never mind the distracting diagrams of arrows pointing to or away from a line rendering of cloud-to-computer relationships. (Disclaimer – there are several definitions of the cloud, but for our purposes, we’ll limit it to Software-as-a-Service or SaaS.) In this case, the applications and data you use reside somewhere other than in your computer or on your company’s network. Instead you access these as a service over the Internet. Hence, SaaS. They are located somewhere in the “cloud”. When you “Google” something, you are using the cloud. Are you a TurboTax customer? Likely you prepared and filed your taxes on line. That was the cloud. Have you purchased or sold anything on eBay? That was the cloud. You don’t know where exactly the servers containing the application and your data or transactions reside, but they are out there in a secure data center environment.

Why the cloud?

Simply put, someone else is managing the service for you. You don’t need to build, staff, manage hardware and software licenses, upgrade, and fix. You leave the job to someone else while you focus on what you need to do without unnecessary distractions. You also only use as much of the service as you need.

It’s like a utility. You pay for it on demand, such as the TurboTax example, or on a subscription basis, like our primeCLAIMS application.

No hassles for you. The application and your data are accessible anytime from anywhere you have a secure connection to the Internet.

What does that mean to Revenue Cycle Managers?

Revenue Cycle Management is complicated enough without worrying about and hassling with the hardware and software needed to prepare, process, submit, and monitor your claims until payment arrives. Using the cloud is simple. You focus only on the revenue collecting tasks at hand and what clearinghouse provides the best solution to meet your needs.

Summary

The cloud has revolutionized how you can monitor and manage claims through a clearinghouse. It speeds up the process, making the process practically transparent. It’s a win-win for all concerned. Just choose carefully. It just make cents.

This is the time of year to open the windows, air out the house, deep clean long neglected spaces, and tidy up. For AR managers, it’s also a good time to “spring clean” the revenue cycle in a few key ways.

1. Update and refresh your payers’ contracts “wiki”. Likely, payer requirements have changed. Know the nuances. Reviewing the contracts and the summary sheet you’ve created for each to make sure your knowledge is current. Make sure your billing practices are consistent with payer expectations. You may think, “But my billing software should be up to date with all changes.” Not necessarily. You will discover that it’s always a good idea to check and to communicate disparities with your vendor. Some areas to focus on: 
   • Levels of care by RUG scores or service levels
   • The level of ICD-10 code specificity required
   • How many days are considered co-pay days
   • Which ancillaries are covered in the base rate and which may be billed separately or not at all
   • If a pre-authorization and re-authorizations for a stay are needed

2. Check the aging. Ask yourself, “Are our payers paying correctly?” Are they paying the contracted rates for ancillary services? The billing software may have it right, but does the payer? Reconcile what you are billing with the actual payments. If you don’t the ripple effect could be significant. A credit on your aging may not really be an overpayment. It may mean you are not tracking payments carefully. This involves more than just answering the question, “Did we get paid?” Instead, you should ask, “Did we get paid correctly and are you recording the payments correctly?

3. Revisit your pre-admission screening procedures. Confirm that the pre-admissions screening procedures cover all the financial bases before admission. This may sound overly simplified, but it is so essential because of the numerous moving parts.

4. Make sure the census is correct. This seems so obvious, but it is so critical. Make sure the census is up to date and entered correctly in the billing software.

5. Stay on top of your Days Sales Outstanding (DSO). Discuss DSO with your team. Evaluate your progress towards reducing it to an acceptable level – ideally around 30 days. Realistically identify what is in your control. For example, Medicaid in some states pay much later than others. Consider DSO carefully, set goals thoughtfully, collect aggressively, and review regularly.

6. Conduct a thorough claims triple check. This should be a multi-disciplinary review of all claims prior to submission. While it may not be practicable to review all claims, identify what could be a reasonable random sampling. You may want to target claims forwarded to a certain payer with which you have had problems in the recent past.

7. Engage the right clearinghouse. Reassess your clearinghouse. You need to be sure that:
   • It knows your business and post-acute payers
   • You see cash flow improvements quarter over quarter
   • Its application is robust with simplified, intuitive workflows
   • It generates accurate and actionable reports
   • That the application is truly enterprise class with single sign-on for ease of access to multiple facilities, especially for designated region and corporate staff
   • The clearinghouse support team listens and promptly responds to your concerns and requests

It’s time to open those windows and let the fresh air in.  Spring clean your revenue cycle. It just makes cents.

Bonus: Discover 5 tips for maintaining your revenue stream in 2016

In a recent blog, we highlighted some benefits of automating secondary claims processing through a clearinghouse. The ROI is potentially huge.

Traditionally billers completed paper forms and mailed them to the payer. Sounds simple, but it wasn’t and, some providers are still submitting claims in this way. Phone calls and error-generated resubmittals contribute to a complex, cumbersome, costly, and prolonged payment process. With electronic claims preparation and submittal, providers can securely submit and track claims to multiple payers all in one portal. Here are some of the advantages a claims clearinghouse can offer:

• Single location electronic claims management with real-time electronic claims verifications
• Smooth claims flow to payers with a significantly reduced risk of rejections - since claims clearinghouses are connected to multiple payers and understand the peculiar format and workflow requirements
• Electronic Remittance Advice (ERA) –view all payments and adjustments
• Claim Status Reports
• Rejection analysis in which the system explains error codes in English
• Edit and correct claims online anytime
• Real-time support

ROI - Secondary claims process saves time

Think of time savings in two ways:

1. Billers’ time – The manual workflow of copying, mailing, and filing claims takes time. Even hand keying claims to each payer takes time. Billers have to know the specific submission requirements of each payer. In a manually-generated claims environment, such complexities can result in errors and slower claims turnaround. With a clearinghouse, such as primeCLAIMS, the system prepares the secondary claims automatically. All billers have to do is review the claims in the Secondary tab and click on the button to send them. It’s simple. And our customers love using it. The ROI? A reduction in claims processing and related costs.

2. Claims turnaround time - Office Managers can go right to the Secondary payer tab once they have downloaded the 835 ERAs (Electronic Remittance Advices). The secondary claims are there for review and submission. No delays. And the claims are accurate and prepared automatically to meet payer-specific requirements the first time. The ROI? A reduction of 4-6 weeks in claims turnaround and payment. One of our customers has stated that it has had a major impact on the reduction of Days Sales Outstanding (DSO).

To give you an idea of what’s at risk, if you are not using a clearinghouse to submit secondary payer claims, take a look at our Secondary Claims ROI calculator and see for yourself. The calculator helps you to identify what revenue may be at risk as well as the time and money it takes to manually generate the claims.

Are you collecting all your secondary claims and how much does it cost to do so?

Check it out.

This month’s revenue cycle management blogs explored a number of topics, including the basic concepts of a claims clearinghouse, how to ensure managed care claims flow smoothly, 3 ways to help your back office runs smoothly, and 8 ways to avoid False Claims Act pitfalls. Here are some highlights from each and links to access each blog in full.

Clearinghouse 101 – a re-introduction to automated claims processing

“Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the tips useful.

Back to the basics.

Ensure Managed Care claims flow smoothly

Partnering with a clearinghouse with connections to thousands of payers makes submitting claims easier and revenue moving.  Keeping cash flow in a steady stream means understanding how managed care works – knowing the systems, procedures, and requirements are critical. A clearinghouse, like primeCLAIMS, has the ability to connect with multiple Managed Care payers, helps to ease the transition into Managed Care and your revenue cycling.

Learn how.

3 ways to make sure the back office is running smoothly during absences

Interruptions, urgent requests, and unanticipated call-ins, even scheduled absences can be disruptive. But retreat is not the answer. Substitute is the better option - making sure that others are trained to cover the important aspects when needed.

Discover how.

The False Claims Act: 8 ways providers can avoid penalties and fines

Periodically, you will see settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed medically necessary, do not meet coverage qualifications, or medical record indicates they were not provided as ordered.

How to avoid them.

Moving the Revenue Needle with Secondary Claims

Now would be a good time to get back to the basics, the essentials, of what a clearinghouse is and offers. “Clearinghouse 101” – an introduction to the some of the critical features and benefits of a claims clearinghouse. Whether you are using one today or not, take a peak. You may find some of the following tips and points useful.

One portal does it all

A clearinghouse becomes the one-stop shop, the aggregator, for all claims processing actions - all in one portal with a single sign-on to submit, respond to, monitor, and manage all claims submitted to Medicare, Medicaid, Managed Care, private insurances, and other 3^rd party payers. Within the portal, billers can make changes or corrections to the claims and have access to DDE, HETS, and claims-in-process.

A claims translator

The clearinghouse takes the claims created within billing software and should run them through a scrubber to make sure that they are compliant with each payer’s requirements. If the clearinghouse find errors, it notifies the billers which claims need what information. Once the clearinghouse verifies that the claims are complete and comply with the payer billing requirements, it converts them into a format readable by the payer and forwards the claims. As a link between the provider and its payers, in essence, a clearinghouse is a claims translator.

Not a billing service

Periodically, someone will ask us if we, a clearinghouse, are a billing service. The straightforward answer is, “No.” A clearinghouse works with a provider's billing service/billers to complete the revenue cycle and to get cash back in your hand.

A convenient tool to monitor, manage, and follow-through

Submitting the claims is one thing, monitoring and follow-through are another. The clearinghouse portal enables you to see into what is happening with the claims once the payer has accepted them. Through the portal, billers can view the entire lifecycle of the claim and take action as needed to keep the claims flow steady.

Create secondary claims automatically

Please refer to this blog to learn more about how a clearinghouse should help to process secondary claims automatically and timely.

Claims data storage

Our clearinghouse, for example, securely stores the data up to 10 years, retrievable for the provider at any time.

Support

Experience and expertise are the foundation of a responsive and reliable support system. A clearinghouse can identify what is acceptable and answer claims submissions and processing questions.

Reports

A clearinghouse should have a core set of useful reports to help billers, their managers, and the executive team to track and trend the claims cycle. The reports offerings should help providers to track their billers and claims.  

The bottom line

From a benefits point of view, what does a clearinghouse offer?

• Simplicity - An effective clearinghouse makes the submission and management of claims simple, easy to learn, and monitor – a single location for claims management.
• Efficiency - From clearinghouse.org, we find that “the average error rate for paper claims is 28%. But using the right clearinghouse can reduce that to 2-3%.”
• Control – A clearinghouse delivers a provider-specific portal which serves as an all-in-one centralized location to monitor, manage, and extract necessary information.
• Speed – A clearinghouse facilitates quicker claims turnaround with higher claims success.
• Peace of mind – With a clearinghouse, billers have the confidence that they can track all claims easily throughout the entire claims-based revenue cycle.

It all makes cents.